Plastic Surgery Blog

This week the FDA has expanded Restylane’s indication for use to include that of lip enhancement. Restylane was the very first hyaluronic acid, injectable filler approved in 2003 by the FDA to fill in the nasolabial folds. Once the FDA approves a product with regards to its safety profile, physicians may choose to use it “off-label” for other reasons. Since being approved for use in the nasolabial fold, physicians have also been using Restylane and other hyaluronic acid fillers in other areas of the face such as the lips, cheeks, and marionette folds.

The expansion of Restylane’s indication for use in the lips now allows Medicis, the company that sells Restylane in the US, to directly market this use to physicians and patients. This will result in an increased awareness of the product and its possibility for use to enhance the appearance of the lips. Remember, it is essential that you seek out the care of a physician who is knowledgeable, experienced and artistic in their use of Restylane in the lips in order to obtain the best possible results.

Click on this video to understand the artistic nature of using fillers in the lips

“Doctor…I want to get rid of the bags under my eyes.” This is a common statement that I hear from new patients on an almost daily basis. In order to determine how to fix these “bags” we must first discover what actually causes them. Are they really bags?

The “bags” under the eyes are commonly caused by protrusion of fat from within the eyelids. This is fat that we all have for our entire lives. As we age, two major things happen to cause the lower eyelid fat to protrude: 1) The ligament that holds this fat within our eyelids actually weakens and 2) We lose volume (fat/bone/muscle) from around our eyes and cheeks.

Traditional surgery for lower eyelids often involves cutting out or removing the fat from the lower eyelid. However, I just told you that there were two main reasons for why those bags form. Neither of those reasons mention that our eyelids got fatter! The unfortunate consequence of removing fat from the lower eyelid is that in some cases, too much fat is removed, and the eyelid can actually appear to be hollow.

In most cases, instead of removing the fat, I reposition or place the fat back into the lower eyelid, where it came from. The best analogy is that of treating the fat like a hernia. It herniated out so we reduce it back into the eyelid. Only minimal fat is removed if any at all.

The next step is to fill in the volume that was lost over the years. This is done using the fat from your own body, called fat grafting. The fat is distilled/purified and then injected in very small amounts back around your eyes and cheeks. This is a long lasting/permanent fix to the lower eyelids.

Treating the “problem” will lead to the most natural looking results. I avoid the “surgical look” by following this principle. In the patient above, I treated her lower eyelids with the above mentioned procedures. She also had laser to reduce the wrinkling under her eyes and the crows feet. She is several months after surgery and notice how she looks like a markedly younger woman in the after picture.

For more information you can visit our blepharoplasty page and our fat grafting web page.

Facial appearance is all about balance and proportion. When considering rhinoplasty it is important to understand that the nose must be shaped to fit the face of the person it belongs to. In my opinion, the thought of a cookie cutter nose is an aesthetic error of gigantic proportions (pun intended).

When analyzing a patient for a rhinoplasty, the surgeon must look at the entire picture and not just focus on the nose itself. What this means is that a nose by itself can look “perfect,” however, when you back up and look at the entire person, that idea of the perfect nose changes. When we look at the noses of people who we deem to be attractive, we can see that they usually have very different appearing noses. There are general similarities and themes that these noses maintain, but transposing Johnny Depp’s nose on Leonardo DiCaprio’s face, would not make an appropriate fit.

A rhinoplasty specialist will look at the entire picture when he/she analyzes the face. Some important factors include the position of the chin, the angle of the forehead, the width of the face, the length of the face, and the height of the patient to just name a few. These factors will influence the decision to achieve a balanced rhinoplasty result that looks like it was the nose you were suppose to be born with.

The patient above was a tall young woman who presented to me for a Rhinoplasty one year ago. The angle of the nose was determined based on her facial shape, height, as well as the amount of slope (length) that we wanted to achieve to her nose. In addition, a small chin implant was placed in order to achieve appropriate balance to her face. The chin implant is noticeable when pointed out because it was the appropriate size and shape for a female of her stature. You can see that it enhanced the overall result of her rhinoplasty, maintaining a very natural look to her nose.

For more information about Rhinopalsty, visit palm beach rhinoplasty.

Botox and Dysport injections are frequently performed to help eliminate facial lines and wrinkles. Another less known use of this products is to improve the appearance of a gummy smile. Some people have a gummy smile when the muscles of the upper lip are overactive. Using Dysport or Botox within these muscles will help relax them and improve the smile. These photos are of a patient 1 week after Dysport injection for a gummy smile.

Lip reduction surgery is performed to reduce the overall size of the upper and/or lower lips. This is in contrast to Lip Augmentation, which is usually performed to enlarge the lip size. Lip reduction has received a great deal of press lately in light of Lisa Rinna having her lips reduced. Since I have seen all kinds of different reports lately about lip reduction, I wanted to shed some light on the topic.

There are several reasons someone may want to have lip reduction surgery:

1) Silicone Injections: I see this most commonly in practice when someone has had some type of permanent lip injection, such as silicone, and the lips have become too large. This is the case in the lip reduction before and after photo shown above.

2)Congenitally Large Lips: Someone is born with excessively large lips, they are self conscious about this, and they would like their lips reduced.

3) Lip Deformity from Injury Finally, I have seen several cases of people that have had some type of an injury to their lips, and scar tissue has formed on one side more then the other. Lip reduction can be performed in order to help obtain improvement in the appearance of the lips in these cases.

The Surgery:
The procedure is most commonly performed in my office procedure room under local anesthesia. All of the incisions are hidden in the back of the lips, so they are not noticeable, and they heal quite well. Swelling is common and can take weeks or more to subside. There is also minimal pain with the procedure, and my patients rarely even need to take any type of narcotic pain medication (though I prescribe it just in case). This is not as difficult of a surgery to recover from as some of the media has made it out to be.

Overall, lip reduction surgery can be very rewarding for people who are afflicted with some of the issues discussed above. I would recommend you see a board certified surgeon who has experience in lip surgery in order to best evaluate the benefit that can be obtained from the procedure.

Fat grafting is a remarkable procedure performed to rejuvenate the face. As we age, we lose volume in the form of muscle, bone and fat from the face. The distribution of this fat loss will vary from person to person. The art of the facial plastic surgeon comes in when deciding where and how to place the fat.

Without question fat grafting is becoming exceedingly more popular. The effects of fat grafting are seen immediately and for years after the procedure. Since fat has a very abundant supply of stem cells within it, some people are calling the fat grafting procedure a stem cell face lift. This might make sense considering that we are injecting stem cells into the face along with the fat, however until I see definitive evidence that the stem cells play any roll in this, I will not tout it in that fashion. What I will say is that fat grafting works well, very well. As the word is getting out about this no incision procedure, more and more people are turning to it.

That being said, the most common question I get is…”How long does it last?” Fat grafting is a permanent procedure. Live fat cells are removed from the body, purified in my lab, and the transferred to the face (all at the same time). The key is making sure that the fat cells survive the sometimes traumatic process of moving it around. Harvesting, processing, and finally injecting the fat in the proper manner will ensure the longevity of this procedure. So bottom line is that the technique is crucial to the outcome and longevity of the procedure, and you must choose a surgeon very experienced in fat grafting to get the best results.

The photo above is of a patient of mine who is 1 year and 2 months after full face fat grafting. The area I want you to pay attention to is that of her cheeks. Although the entire face was injected, we will use the cheeks to demonstrate that after 14 months the cheeks are still full, and even fuller then they were at 2 months. At this point there is no question that the fat has taken and is now a part of her face.

The advent and popularization of the fractional CO2 laser has been a big step forward in reduced downtime laser peels that actually work. Since purchasing the latest, Premium model of the fractional eCO2 laser, we have amassed a significant clinical experience with the laser.

As with any tool, the CO2 laser can be used in many different ways. This is akin to giving a surgeon a scalpel. A facelift can be performed with this tool, as much as a rhinoplasty or a removal of an appendix. The laser is no different as there are multiple combinations of energy, density, and methods of delievery of the pulses.

This being said, over the past year we have used this laser with remarkable results and only 4-5 days of downtime. However, some of our patients could not even afford that kind of recovery due to there busy schedules. This has led us to develop a protocol for a no downtime fractional CO2 laser peel that works! The laser settings that we have developed allow the procedure to be performed with none of the downtime of the already low down time fractional peel.

The Express CO2 Peel is performed over a course of 3 treatments. These treatments are performed 3 weeks apart. The settings are tweaked with each treatment in order to provide the best results with no downtime. The procedure takes a total of 20 minutes to perform each time. Thus far, every patient that had this peel performed has referred friends in for the remarkable results.

Before undertaking any cosmetic procedure you must first understand what the goals of that procedure are. Since a picture is worth a thousand words, we put together this video of the Deep Plane Facelift complete with before and after photos. It explains the results of the surgery with commentary on the before and after photographs. To see videos about facelift surgery and the recovery involved. Please visit the facelift video page.

It has been said that the eyes are the window to the soul. This speaks loudly, as the goal of any facial rejuvenation procedure is to restore attention back towards the eyes. What happens when that window is missing its drapes!

We often see patients that come in and have had prior blepharoplasty or eyelid surgery, where too much fat or skin has been removed. This defeats the purpose of cosmetic surgery as it does not make you look younger. In fact it makes you look older and un-natural.

A youthful eyelid is almost always associated with fullness around the eyes. Just take a look at any current fashion magazine. Take a look at some of the famous actresses and models today. All of them, almost invariably, have fullness to their eyelids.

That being said, preservation of this fullness must be maintained whenever performing eyelid rejuvenation and blepharoplasty. This means removing just the right amount of skin from the upper eyelid, and in most cases NEVER removing fat from the lower eyelid. For this reason, I perform a fat repositioning lower eyelid blepharoplasty that moves the protruding fat downwards instead of removing it, in order to prevent that hollowed out look. This is a story for another day, but you can read more here.

So what happens if too much skin, fat, etc. has been removed? This can be a difficult problem to treat. It is restorative plastic surgery. The case below is a woman who had no extra skin or fat in her eyelids (from prior surgery), yet she looks older purely because her eyes are too hollow. Since are minds have a harder time thinking in terms of addition (adding volume), I will show you these before and after fat grafting photos to give you a better idea. Take a look at how fat grafting her periorbital region (upper and lower eyes) has given her back years of youth and restored an attractive,youthful eyelid: